This inspection took place on 29 and 31 May 2018 and was unannounced on both days.

Burley Hall is a ‘care home.’ People in care homes receive accommodation and nursing or personal care as a single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. The care home can accommodate up to 51 people who require nursing care and people who are living with dementia. At the time of this inspection there were 33 people using the service. The service is split into two units; Wharfedale and Greenholme.

Our last inspection took place on 8, 18 and 31 August 2017 and at that time we found the service was not meeting nine of the regulations we looked at. These related to safe care and treatment, safeguarding service users from abuse and improper treatment, person centred care, dignity and respect, need for consent, meeting nutrition and hydration needs, fit and proper persons employed, staffing and good governance. The service was rated ‘Inadequate’ and was placed in special measures.

Services that are in Special Measures are kept under review and inspected again within six months. We expect services to make significant improvements within this timeframe. This inspection was therefore carried out to see if any improvements had been made since the last inspection and whether or not the service should be taken out of ‘Special Measures.’

During this inspection the service demonstrated to us that improvements had been made and is no longer rated as inadequate overall or in any of the five key questions. Therefore, this service is now out of Special Measures. However, while we concluded improvements had been made they needed to be fully embedded and sustained to make sure people consistently received safe, effective and responsive care and treatment. This is reflected in the overall rating for the service which is now ‘Requires Improvement.'

The regional support manager had been managing the service since November 2017and during that time has made significant improvements and was highly regarded by people who used the service, relatives and staff. They have now returned to their substantive post as a manager has now been appointed.

There was a new manager in post who was going through the process of registering with CQC. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff were being recruited safely. Duty rotas were organised to provide enough staff to provide care and support. On Wharfedale unit we saw the care staff team were supported seven days a week by a mealtime hostess, however, on Greenholme unit there was no hostess cover at weekends, so care staff had to undertake additional tasks, taking them away from their caring duties.

Staff were receiving appropriate training and they told us the training was good and relevant to their role. Staff were receiving formal supervision where they could discuss their ongoing development needs.

People who used the service and their relatives told us staff were helpful, attentive and caring. We saw people were treated with respect and compassion.

Care plans were up to date and detailed what care and support people wanted and needed. Risk assessments were in place and showed what action had been taken to mitigate any risks which had been identified. People felt safe at the home and appropriate referrals were being made to the safeguarding team when this had been necessary.

People were supported to have maximum choice and control of their lives and staff supported them in the least restrictive way possible; the policies and systems in the service supported this practice.

People’s healthcare needs were being met and me

This inspection took place on 8, 18 and 31 August 2017 and was unannounced. The previous inspection had taken place on 5 January 2017 and at that time we found the provider was in breach of Regulation 17: Good Governance and Regulation 18: Staffing.

This inspection was carried out to see what improvements had been made since the last inspection. During the current inspection we found the provider was in breach of nine regulations again including the two regulations already proven at the last inspection. The current breaches are: Regulation 9: Person Centred care; Regulation 10: Dignity and respect; Regulation 11: Need for consent; Regulation 12: Safe care and treatment; Regulation 13: Safeguarding service users from abuse and improper treatment; Regulation 14: Meeting nutritional and hydration needs; Regulation 17: Good governance, Regulation 18: Staffing and Regulation 19: Fit and proper persons employed.

Burley Hall Nursing Home is located in Burley-in-Wharfedale near Ilkley and provides nursing and personal care for up to 51 older people, some of whom are living with dementia. There were 42 people using the service when we visited. Accommodation is provided in two houses and during the current inspection Greenholme House was accommodating 16 people living with dementia and Wharfedale House was accommodating 26 people with nursing needs. There are communal areas on each house and access to garden areas.

At the time of our inspection the service was without a registered manager. The manager was going through the Care Quality Commission (CQC) registration process. A registered manager is a person who has registered with the CQC to manage the service. Like registered providers, they are 'registered persons'. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Whilst people and relatives generally shared positive experiences about the home and said good quality care was provided for the most part that met people’s individual needs, there were several areas within the home which did not meet the required standards. During the last inspection we found low staffing levels and poor staff morale and at this inspection we found these issues had still not been addressed effectively. Staff and people who used the service told us there were not

enough staff to keep people safe at all times. We identified this as a continued breach of regulation.

Furthermore with regard to staffing, the staff members spoken to at this inspection told us they were not adequately or consistently supported. Whilst staff were up to date with training on safe working practices and recruitment records demonstrated there were systems in place to employ staff who were suitable to work with vulnerable people; recruitment procedure was not always followed and there were not sufficient numbers of staff hired to meet the needs of people living in the home. With regard to staff supervision the regional director told us the service was trying a new supervision system where supervision is held when staff request or when management feel there is a need.

People told us they felt the service was safe and staff spoken with had a good understanding of safeguarding and knew how to report any concerns about people's safety and welfare. However, we found management had not reported all safeguarding concerns to the local safeguarding team and the CQC. We identified this as a breach of regulation.

We found people's medicines were not managed safely. Records showed creams and lotions known as ‘topical medicines’ were not applied as prescribed. We also found people had received their night medications well before the recommended time. We identified this as a breach of regulation.

We found staff were not working in accordance with the Mental Capacity Act which meant people's rights were not always protected.

Staff were able to tell us how individ

This inspection took place on 5 January 2017 and was unannounced. At the last inspection on 7 April 2016 we rated the service as ‘Requires Improvement’. Although we did not identify any breaches of regulation, we had some concerns regarding leadership within the home.

Burley Hall Nursing Home is located in Burley-in-Wharfedale near Ilkley and provides nursing and personal care for up to 51 older people, some of who are living with dementia. There were 37 people using the service when we visited. Accommodation is provided in two houses; Greenholme house accommodates up to 17 people living with dementia and Wharfedale house accommodates up to 31 people with nursing needs. There are 45 single rooms and three shared rooms, which are currently used for single occupancy. There are communal areas on each house and access to garden areas.

Overall people and relatives provided positive experience about the home and said good quality care was provided that met people’s individual needs. However some people and relatives raised concerns about lack of staff and poor staff morale.

People said they felt safe living in the home. Risk assessments were in place which showed risks to people’s health and safety had been assessed and clear plans of care put in place. In most cases we saw safeguarding incidents were appropriately managed, although we identified one incident which had not been reported to management for action.

Overall medicines were safely managed, although due to inconsistent record keeping there was a lack of accountability for some medicines.

We concluded there were not always sufficient staff deployed to ensure consistently safe care and treatment. Staff all told us there were not enough staff, particularly in the Greenholme house and we observed several instances where staff were not present to safely oversee communal areas.

Safe recruitment procedures were in place to help ensure staff were of suitable character to work with vulnerable people.

Staff received appropriate induction and refresher training in key subjects to help ensure they had the correct skills and knowledge to care for people. People told us staff were competent and staff demonstrated to us they knew people well and their individual needs.

People had access to a choice of suitably nutritious food. Arrangements were in place to ensure people’s nutritional needs were met and action was taken where people were deemed to be at risk.

The service was acting within the legal framework of the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS).

People’s healthcare needs were met and appropriate plans of care put in place. The service liaised with external health professionals where required.

People and relatives said staff were kind and caring and treated them in a respectful manner. This was confirmed by our observations of care and support. Regular staff knew people well and positive relationships had developed.

People’s care needs were assessed and detailed and appropriate plans of care put in place. We saw in most cases care plans were followed. However we found a lack of evidence pressure area care interventions were carried out in line with plans of care.

Two activities co-ordinators were employed who provided people with a varied range of activities.

A system was in place to log, investigate and respond to any complaints. Most people and relatives we spoke with were satisfied with the care provided.

Staff told us morale was poor, there was a lack of team working and/or they did not feel well supported by management. We were concerned of the impact widespread negative staff sentiment could have on the overall quality of the service provided.

Systems to assess, monitor and improve the service were in place. In some instances we saw these were successful in highlighting issues and driving improvement, but further work was needed to review some areas such as medication and care and support charts.

People were

This inspection took place on 7 April 2016 and was unannounced. At the last inspection on 3 and 5 November 2015 we rated the service as ‘Inadequate’ and in ‘Special Measures’. We identified six regulatory breaches which related to safeguarding, staffing, person-centred care, medicines, complaints and good governance. We issued warning notices for the breaches of medicines, staffing, person-centred care and good governance with a compliance date of 11 January 2016. We issued requirement notices for the breaches relating to safeguarding and complaints. Following the inspection the provider sent us an action plan which showed how the breaches would be addressed. This inspection was to check improvements had been made and to review the ratings.

Burley Hall Nursing Home provides nursing and personal care for up to 51 older people, some of who are living with dementia. There were 42 people using the service when we visited. Accommodation is provided in two units – Greenholme unit accommodates up to 17 people living with dementia and Wharfedale unit accommodates up to 31 people with nursing needs. There are 45 single rooms and three shared rooms, which are currently used for single occupancy. There are communal areas on each unit and access to garden areas.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The registered manager was not present during the inspection as they were on leave. The clinical services manager and other senior managers from the organisation assisted the inspectors.

People told us they felt safe and we found there were enough staff on duty to meet people’s needs. A staffing tool was used to ensure staffing levels were appropriate and based on people’s dependencies, which had not been in place at the last inspection. We found risks to people were assessed and managed to ensure people’s safety and well-being.

We found improvements in the way medicines were managed, which ensured people received their medicines safely and when they needed them.

Staff had a good understanding of abuse and knew the reporting systems under safeguarding procedures. We saw records which showed safeguarding referrals had been made. However, records showed three incidents where abuse was alleged and managers were unable to provide us with evidence to show these had been dealt with appropriately. Managers told us they would investigate these matters further and report back to us. Following the inspection we received information from the provider which confirmed action had been taken to address these matters.

The home was clean and well maintained and service certificates for the premises and equipment were up-to-date.

Robust recruitment processes ensured staff were suitable to work in the care service. We found staff received the induction, training and support they required to carry out their roles.

People told us they enjoyed the food. Lunchtime was a pleasant experience with people offered choices and given the support they required from staff. People’s weights were monitored to ensure people received enough to eat and drink.

People had access to healthcare services and we saw people benefitted from specialist input. For example, one person’s walking had improved with support from the physiotherapist.

The home was meeting the requirements of the Deprivation of Liberty Safeguards (DoLS) and acting within the legal framework of the Mental Capacity Act (MCA).

People and relatives spoke highly of the staff who they described as ‘very good and ‘very kind’. People spoke positively of the care they received and we saw staff treated people with respect and ensured their privacy and dignity was maintained.

We s

People who used the service told us they enjoyed living at Burley Hall and were complimentary about the care provided by staff. One person said "The care and facilities available are excellent.” Another said "I could not be happier with the care I receive."

People were also very complimentary about the meals, they said there was always a good choice of food and they had more than enough to eat. They told us they were able to make suggestions and requests about changes to the menu and f they didn’t like what was on the menu they were able to ask for something different to be prepared. One person told us “The meals provided are first class and the service is excellent.”

We spoke with four visitors and they told us they were pleased with the standard of care and facilities provided by the service. One person told us “I am extremely pleased with the care my relative receives and I am always kept informed if there is any changes in their general health and wellbeing."

The nursing and care staff we spoke with demonstrated a good knowledge of people's needs and were able to explain how individuals preferred their care and support to be delivered. We found the atmosphere within the home was warm and friendly and we saw staff approached individual people in a way which showed they knew the person well and knew how best to assist them.

Our inspection on the 3 October 2012 found we had minor concerns that there was insufficient staff to meet peoples needs. The provider wrote to us on 16 November 2012 and told us they would take action to ensure they were compliant with this essential standard. They told us these actions would be completed by the end of November 2012. We carried out this visit to check improvements had been made.

We talked with three people who used the service on the residential unit all told us there were enough staff to meet their needs. They said most of the time staff had responded promptly when they used their call bells and the staff had the time to talk to them whilst they were helping them with their personal care. One person told us the staff had asked them regularly whether they were comfortable and needed any help.

All said they were satisfied with the service provided and told us the staff treated them with dignity and respect. At this inspection we found improvements had been made and there were sufficient staff to meet people’s needs.

The people we spoke to told us that they felt included in their care, were cared for well and comfortable at the home. People felt safe and comfortable in speaking to staff about concerns or problems.

This inspection took place on 3 and 5 November 2015 and was unannounced. At the last inspection on 31 January 2014 we found the home was meeting the regulations.

Burley Hall Nursing Home provides nursing and personal care for up to 51 older people, some of who are living with dementia. There were 48 people using the service when we visited. Accommodation is provided in two units – Greenholme unit accommodates up to 17 people living with dementia and Wharfedale unit accommodates up to 31 people with nursing needs. There are 45 single rooms and three shared rooms, which are currently used for single occupancy. There are communal areas on each unit and access to garden areas.

The home has a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Before the inspection we received a number of concerns stating there were not enough staff to meet people’s needs, particularly on Wharfedale unit. Our discussions with people, their relatives and staff and our observations during the inspection confirmed this. We found people’s needs were not met in a timely way and duty rotas showed staffing levels had fallen below the levels stated by the registered manager on many occasions in the weeks prior to the inspection. There was no tool used to calculate the staffing levels and the registered manager told us staffing levels were based on numbers and people’s dependency levels were not considered. We found this was a breach of regulation as there were not enough staff to meet people’s needs.

People told us they felt safe in the home and our discussions with staff showed they understood the safeguarding procedures; however we found some incidents had not been referred to the local authority safeguarding unit or notified to the Commission. We found this was a breach in regulation as safeguarding incidents were not always recognised or reported appropriately.

We found systems in place to manage medicines were not always safe which meant people were at risk of not receiving their medicines when they needed them. We found this was a breach in regulation as people’s medicines were not managed safely.

Recruitment procedures ensured staff were suitable and safe to work with people. Staff received the induction, training and support they required to carry out their roles and meet people’s needs. Nurses on Greenholme unit were involved in a project with Bradford University to heighten staff awareness of the needs of people living with dementia and ensure their individual needs were met.

The registered manager understood the legal requirements relating to the Mental Capacity Act (MCA) 2005 and Deprivation of Liberty Safeguards (DoLS). An authorised DoLS was in place for one person and eleven other applications had been made for DoLS authorisations.

We found the home was clean, well-maintained and decorated and furnished to a high standard. People’s rooms were personalised and communal areas were comfortably arranged so people could sit in small groups relaxing and chatting with each other.The home employed activity co-ordinators and there was a varied activity programme of events both in house and out in the community.

People’s feedback about the food was mixed; some people praised the food, whereas others were less positive. Menus showed a wide variety of meals and mealtimes were well organised with staff providing people with assistance as required. However, we found people’s nutritional needs and weight were not monitored or reviewed to make sure they were receiving sufficient to eat and drink. We found this was a breach in regulation as people’s care needs were not being met.

People praised the staff describing them as ‘excellent’, ‘extremely kind’ and caring. We saw staff maintained people’s privacy and dignity and encouraged their independence. People had access to healthcare services and professionals we spoke with confirmed staff acted upon advice given.

We found differences on the two units in how care was planned and delivered. On Greenholme unit nurses were working with staff to ensure people received person-centred care using the knowledge gained from the project work with Bradford University. However, on Wharfedale unit we found care was not responsive to people’s needs and focussed more on the completion of tasks. This meant people’s individual needs and preferences were not always recognised or met. We found this was a breach in regulation as people’s care needs were not being met.

There was a complaints procedure and we saw evidence which showed the procedure had been followed in relation to some complaints. However, during the inspection we were made aware of two complaints which had not been dealt with or responded to appropriately. We found this was a breach in regulation as complaints were not being dealt with appropriately.

Accidents and incidents were recorded, however there was no overall analysis to identify trends or themes and consider ‘lessons learnt’ to reduce the likelihood of re-occurrence

People, staff and relatives gave mixed feedback about the leadership and management of the home. Some said they found the registered manager approachable, responsive and effective, whereas others stated the opposite describing them as someone who did not listen, was unapproachable and ineffective. Systems were in place to monitor and assess the quality of the service such as audits of medicines and care plans, as well as regularly monitoring visits by senior managers. However, these systems were not effectively used to identify and address areas for improvement to ensure that the quality of care continually improved. We found this was a breach in regulation as there was not good governance.

We identified six breaches in regulations relating to staffing, medicines, complaints, safeguarding, person-centred care and quality assurance. You can see what action we told the provider to take at the back of the full version of the report.

The overall rating for this service is ‘Inadequate’ and the service is therefore in ‘Special measures’.

Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months.

The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe.

If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration.

For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.